CPW 400 P x 100 L PSF 63/15-16 Form No. N.B.

/5
Form No. 28 (28, 28A, 28B, 28C, May 77)

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l.Jff INSURANCE CORPORATION Of INtlfA

CHENNAI DIVISION- I

SALARY SAVINGS SCHEME AuTHORISATION LETTER

(To be filled in duplicate by the proposer, except for the details under the Item "Policy Particulars")
To Place:

Date:

Dear Sir,
I have taken out a life insurance policy with the Life Insurance Corporation of India under the Salary
Savings Scheme. The particulars of the Policy are given overleaf. I desire to pay premiums by deduction from
salary every month. I request you to kindly arrange to deduct and pay to the Sr. / Branch Manager Life Insurance
Corporation of India, Branch Code No the premium
amount stated overleaf from my salary due for the month given overleaf and also continue to deduct and pay
such amounts regularly every month including arrears of premium if any with interest.
I agree that your liability will be confined to making arrangements for deduction of premium from salary
whnever this can be made and for remitting the amount of deduction to the Corporation in time up to the month
and year. of last instalment stated overleaf or till I give you and the L.I.C. a specific Notice of withdrawal of
authorisation. I also agree that the Notice of authorisation shall not be withdrawn by me until premiums have
been paid for a minimum period of three years from the date of commencement of the policy. I shall be entirely
responsible for any consequence on account of non-payment of premiums on my policy for reasons beyond
your control such as the event of my proceeding on leave without payor my drawing advance salary without
deduction of premium perchance or my withdrawing this authorisation by a due notice to you and to the Corporation
after the minimum period as stated above by being transferred to an office where the Salary Savings Scheme has
not been introduced (or my being transferred on promotion to a gazetted post where the Salary Savings Scheme
is not operative) * or my leaving present service in any such case of withdrawal of Salary Savings Scheme with you
by the Ufe Insurance Corporation of India for any reasons whatsoever, it will be my responsibility to make arrangements
for remittance of premium directly to the Ufe Insurance Corporation of India to prevent my policy from lapsing.

IMPORTANT Yours faithfully,

For Attention of Proposer / Policyholder

Kindly ensure deduction of premiums
from salary to avoid lapsation of the policy
(Signature of the Policy Holder)
*Delete wherever inapplicable
1. (a)PolicyHolder'sParticulars:
Name in full (in Block letters) .
Phone No. : Landline Cell No .

E-mail of the Employee: E-mail of the Employer: ..

Short Name for Correspondence .

Designation / Salary No. / Badge No. / Token No. / P.C. No. Etc.
Office of Service .
Department / Office ..
Office Address ..
Permanent I Residential Address : :.

Other Policies already under the Salary Savings Scheme ..

 (b) Additional information to be furnished by T.N.E.B.Employees only:
Salary RollNo./Token No./BadgeNo ·.····················
...............................................................................•.......
C.P.F.,G.P.FAccountNo.: ; .
(i) Please state whether you are permanent employee of
the Board (Please enclose a certificate to that effect). . .

(ii) If you are a non-permanent employee, please state the

period of continuous service with the Board. . .
(iii) If you are coming under item (ii) above and if you
have put in at least 5 years of continuous service, a
certificate from the Board to the effect whether you are
likely to be retained in theservice of the Board without
break should be produced. Please state whether such
a certificate is enclosed. . .
(c) Additional Information to be furnished by Employees of Madras Municipal Corporation:

PayingAuthorityCode No : .

EmployeeCode No.I TokenNo. : .

Whether a Labour Staff

convertedto Establishment : .
(PA Code No. 7742)
If so:
(i) Code No. of pay DisbursingOffice : .
(ii) LocationCode No. : ..;...........................................................................•.......................
; .

Signature of Policy Holder

2. Paying Authority (Salary drawing and I or disbursing OffIcer particulars)

Designation :
Office Address & Place :
P.A.Code No Sub - Code No ..

3. Policy particulars (to be completed by LI.C.) Agency Code No , .

BranchCompletingthe Policy .
ServicingBranch. Code No .
*Policy Number : Sum Assured:
Plan and Term : Date of Risk
* Instalment of premium Rs. Deduction to commence from Salary
Payable on or after 1st.. 200
Month and year of Last Instalment of premium.

*In the case of Policies Issued under Progressive Protection Plan and Convertible whole Life Plan varying
amounts will be required to be deducted as detailed below :
Instalment Premium Deduction to commence from Premium payable
Salary for the month of

(i)
(ii)
(ii) P.Sr./ Branch Manager